Robbie has cerebral palsy and uses a feeding tube and a wheelchair. He's nonverbal but a decidedly happy boy, often giggling as he whips his head from side to side.

He responds to whistling with an open-mouthed grin and gets quiet when one of his favorites, Celine Dion, plays on the speaker.

So last fall when he started crying more often and pulling his left wrist to his chest to guard it, Robbie's dad, Bill Elam, knew something was wrong.

Robbie Elam laughs in the living room​ of his Amory home.(Photo: Sarah Warnock/Clarion Ledger)

Robbie has severe medical problems and has lived in and out of a hospital for the last year. At the end of last summer, he spent five weeks at his home hospital, Children's of Alabama in Birmingham, with pancreatitis.

In December, after doctors found Robbie's wrist was fractured, Elam said the Mississippi Department of Child Protection Services suspected him of abuse. The father couldn't explain what caused his son's injury. Elam has taken care of Robbie full time since his mom left and moved to Alabama several years ago.

Then, in January, doctors discovered another bone fracture on Robbie's femur on the left leg.

"That's when they went haywire," Elam said of CPS. Caseworkers were showing up to his house — an admitted work in progress with several pending renovation projects — several times a week.

But it wasn't until months later, after Elam hired an attorney, that the Monroe County Youth Court referee knew anything about the abuse case. CPS policy mandates investigations into low-risk cases be wrapped up within 30 days.

The referee, or acting Youth Court Judge Sam Griffie, filed an intake order on the case March 9 and immediately recommended no action be taken. He had learned the circumstances surrounding the case, including the likelihood that the fractures resulted from medical problems.

"There should not be a case of alleged abuse where the Youth Court knows nothing about it. It should have been reported to the intake officer," CPS Commissioner Jess Dickinson told the Clarion Ledger. "If we suspected abuse, like a broken wrist, we would have to report that to the intake person at the court and the Youth Court judge would have to decide whether and when to set a shelter hearing."

The agency is bound by confidentiality, so Dickinson could not comment on Elam's case, but he promised to investigate.

The door to Robbie Elam's door is decorated with signs from a previous hospital visit.(Photo: Sarah Warnock/Clarion Ledger)

Child Protection Services is in flux as it attempts to meet requirements in a long-running legal settlement while not receiving all needed funds from the Legislature. The state was originally sued in 2004 and accused of not meeting its obligation to protect abused and neglected children.

Dickinson is now looking for areas of the budget to cut $23 million, which he said will put the agency out of compliance with caseload requirements that aim to limit the number of abuse or neglect cases per caseworker.

Elam said the caseworkers on Robbie's case were persistent; it was the questions they didn't ask that troubled the father.

Robbie has around-the-clock nursing care, including at East Amory Elementary school where he takes special education classes.

Yet, no CPS caseworkers interviewed any of Robbie's nurses, Elam said. One in-home nurse said she remembered CPS caseworkers coming into the home, but they never questioned her.

Even after the judge's March. 9 order, the workers kept showing up at Elam's home until the end of March.

"You didn't do an investigation," Elam said of CPS. "You didn't come up with anything other than saying I had to have done it … I want to know (what caused the fractures) more than anybody else."

The answer, for Elam, came in the form of a personal injury attorney advertisement his adult daughter happened to see on television.

"If you suspect that your child was hurt by Neocate, it is important that you contact an attorney right away," one of the ads reads.

Neocate — all Robbie eats — is an amino-acid based formula for infants and children with specific nutrition needs and allergies. It has recently been associated with low phosphorus levels, which can cause unexplained bone fractures in some children with severe medical conditions.

Shelving in Robbie Elam's bedroom holds medical supplies, stuffed toys and some of the formula Robbie's father Bill believes may be responsible for Robbie's phosphate level issues and alleged related maladies. An unplugged video camera in the upper right corner was initially placed by the Elam family to monitor Robbie's room and all internal activity.(Photo: Sarah Warnock/Clarion Ledger)

Phosphorus is equal to calcium in importance for strong bones.

In April 2017, the medical journal BONE published a report showing an association between Neocate and cases of hypophosphatemia, a condition caused by imbalanced electrolyte levels that can lead to unexplained fractures or rickets.

The authors identified 51 children at 17 institutions with hypophosphatemia related to the elemental formula.

"Although the skeletal disease had often been attributed to underlying disease, most all improved with addition of supplemental phosphate or change to a different formula product," reads a summary of the report.

Although the link between his bone fractures and the formula is not certain, in February and March, Robbie spent five weeks at Children's of Alabama to ween off Neocate, the side effects of which Elam said were tantamount to "withdrawing from some illegal drug."

Elam received call after call from CPS during their time in the hospital.

There's no harm in being investigated, Elam said, but "they were not investigating what they should be."

"I thought they might investigate other causes, the nurses, and the school, instead of me having to find out from a commercial," Elam said. "If my daughter didn't see that on that commercial, they'd have taken my kids away from me ... We wouldn't have known to raise hell about this; to go to Birmingham to get it figured out; to say, 'Why is my child's bone fractured?' We knew he had a fracture, and I know they had to report it. To be honest, I thought one of the nurses had did it. I made the assumption it was the nurse. I was wrong."

Elam said his son's phosphorus levels tested low in February and his T-score was -3.5, indicating very low bone density.

"It takes a while for kids, any kid, to have a low phosphorus level and then that lead to a fracture," said Dr. David Galloway, a gastroenterologist at Children's of Alabama. "To me, that says no one was checking to begin with."

Elam said Robbie's phosphorus levels were only checked in February after he raised questions about the BONE study to his Children's of Alabama doctor.

"We didn't know to do that before now," Elam said.

Galloway, who sees about a dozen of children on Neocate, said he's not identified any problems with the formula in his patients, whose phosphorus levels he checks regularly.

Neocate is still a safe formula option for the majority of children, Galloway said, and the BONE study is a learning opportunity.

"Medicine is not perfect. Doctors don't have all the answers. We would love to, but we don't," Galloway said. "It is important to forever be learning and asking questions."

A spokesperson for Nutricia, which makes Neocate, said while the patients highlighted in the BONE study represent a small segment of Neocate users with unique conditions, the company has assembled an expert panel and issued guidance to health care professionals about monitoring these patients.

"Recently, we began to integrate a more highly-soluble phosphate into our Neocate line of formulas. The updated formulation will begin to roll out beginning in April," the statement reads.

Another 2017 study published in UK-based journal Bone Abstracts made similar findings and urged clinicians to "exercise caution" in using elemental formula.

The home of the Elam's in Amory​ is outfitted for wheelchair access.(Photo: Sarah Warnock/Clarion Ledger)

In 2017, Clinical Case Report published a report called, "It is not always child abuse: multiple fractures due to hypophosphatemic rickets associated with elemental formula use."

In child abuse cases, fractures are common, found in 25 to 50 percent of abused children, according to the report. They're also the most common type of accidental injury, accounting for between 8 and 12 percent of pediatric injuries.

"The suspicion of child abuse, when the injuries are limited to the skeletal system, should lead to attempts to find an alternative cause of injury, particularly osteogenesis imperfecta and rickets," the researchers write.

CPS is supposed to work with Benton and University of Mississippi Medical Center, to evaluate children during abuse investigations. UMMC runs the state's "Children's Safe Center Fund," which is supposed to "serve as a resource for the assessment, investigation and prosecution of child maltreatment."

But like CPS, the safe center is short on resources.

"It's such a huge task that we need more money," Benton said. "The challenge is one of resources mostly."

Benton never evaluated Robbie, Elam said.

Elam said when he finally got the judge to open and close the abuse case, it was as if the caseworkers had no knowledge of the order.

Before the fractures were reported, CPS had already received an anonymous call with concerns about the supervision of the children living in Elam's house — his three boys and a friend's daughter — in November. Elam had been letting a friend stay at his house for a while and the anonymous complainant had concerns about the kids bathing and changing clothes in front of each other.

"They never contacted Youth Court and opened a case of neglect, which they should have done in the first 30 days if they thought there was neglect," Elam's attorney, Petesy Smith said.

According to numbers from Child Protection Services as of April 3, 42 investigations were open past the 30-day window allowed by their policy. These ranged from 31 to 88 days old.

"Reasons for the lag time vary widely," a CPS spokesperson said in a statement, "but the major reason explained in the case reports is difficulty in locating and interviewing all of the parties involved in the case."